Diaphragmatic Hernia Defects Research Articles

Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia: A Technical Report.

Introduction: Occult diaphragmatic hernias after trauma are relatively rare and may present months to years after the traumatic event. Clinical presentations range from asymptomatic incidental findings on imaging to life-threatening incarceration of abdominal visceral organs. This study presents a case of a patient with a symptomatic diaphragmatic hernia secondary to a trauma >30 years prior. A literature review of this defect was performed examining the pathophysiology, presentation, and operative considerations. Case Presentation: A 58-year-old male with a history of multiple traumatic motor vehicle accidents 30 years prior presented with abdominal pain and obstructive symptoms. Axial imaging demonstrated a right-sided diaphragmatic hernia defect containing small intestine, colon, and omentum. He ultimately underwent a transabdominal laparoscopic repair of the defect with mesh buttressing. Postoperative the patient recovered well and was discharged without complications. Conclusion: Limited data outside of case reports exist for surgical management of occult diaphragmatic hernias secondary to trauma. Reported management options include open and minimally invasive thoracic as well as open and minimally invasive abdominal approaches; each with advantages and disadvantages. Depending on the defect size, both primary repair and repair with mesh reinforcement are appropriate options. More data comparing the approach and repair technique are needed to determine the best technique.

Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia

Introduction: Blunt trauma may cause small occult diaphragmatic injuries that increase in size over the course of decades. The gradual increase is secondary to the pressure disparity between the abdominal and thoracic cavities. Over time, visceral contents may traverse the defect and become incarcerated within the thoracic cavity.1 Typically, the defect occurs on the left side with gastric herniation. Rarely, the defect occurs on the RIGHT side since the large right lobe of the liver may preclude herniation through a right-sided diaphragmatic defect.2,3 This video presents a repair of a symptomatic right-sided diaphragmatic hernia that occurred decades after blunt trauma. Materials and Methods: A 58-year-old man was admitted to the emergency department with a 2-day history of acute abdominal pain that was sharp and diffuse. He had vomited several times and denied flatus for 24 hours. He had a history of three prior motor vehicle accidents in the 1980s. He had a history of oropharyngeal cancer that was treated with radiation then a neck dissection 2 years before presentation. He had no history of abdominal or thoracic surgery but had a significant tobacco history for 40 years. His blood work was normal. A CT scan of the abdomen showed a right-sided diaphragmatic hernia defect that contained small intestine and colon. There was no dilated bowel or evidence of a pneumoperitoneum or free fluid. There was air in the rectum. A well-healed old nondisplaced pubic rami fracture was evident also on the scan. Surgical intervention included a laparoscopic possible thoracoscopic diaphragmatic repair. Operatively, he was placed in a semilateral position at 30°. A Veress needle was used to enter the abdomen and three 5 mm ports were placed along the subcostal border. One of the 5 mm ports was upsized to a 10 mm port. Diagnostic laparoscopy delineated the diaphragmatic defect containing bowel. Several adhesions were divided and the colon and small intestine were reduced from the defect. There was no hernia sac and the thoracic cavity was pristine. Once the bowel was reduced, the defect was measured at ~5 cm by 3 cm. The defect was closed with interrupted 0-silk sutures. The suture line was then buttressed with a 15 cm by 10 cm mesh. The mesh was secured with absorbable tacks. A 28F chest tube was placed. Results: The operative time was 90 minutes. The patient was started on a clear liquid diet on postoperative day 1 and advanced to a regular diet on postoperative day 2. Because of social issues, he was discharged on postoperative day 4. A chest CT at ~6 months postoperatively showed no evidence of a recurrent diaphragmatic defect. Conclusions: Minimally invasive techniques are well suited for diaphragmatic defects. If a right-sided symptomatic diaphragmatic hernia is diagnosed, a minimally invasive approach through the abdomen may be performed without a thoracic approach. Adhesions may warrant thoracic access to reduce the abdominal contents, so double lumen intubation is prudent. A durable repair may be obtained by suturing the defect and adding a mesh buttress. Patient consent has been obtained. Authors have received and archived patient consent for video recording/publication of the procedure. There are no conflict of interests associated with this video in terms of commercial or financial interests. Runtime of video: 5 mins 42 secs

Congenital Right Diaphragmatic Defects

Background:The descriptive clinical study was conducted to analyse the clinical profile as well as the outcome of congenital right diaphragmatic defects among children including neonates in a tertiary care referral neonatal and paediatric centre in southern Karnataka, India.Materials and Methods:This retrospective and prospective observational clinical study was conducted from January 2005 to August 2019, over a period of 14.7 years in a tertiary care referral neonatal and paediatric centre. Clinical characteristics and risk factors of 33 children including neonates admitted and diagnosed with congenital right diaphragmatic defects were assessed both pre- and postoperatively. Neonates and children with acquired right diaphragmatic hernia defects and the left-sided diaphragmatic defects were not included in this clinical study.Results:For statistical as well as clinical analysis, 33 study subjects were grouped into four groups, depending on the pre-operative and intraoperative findings as well as on their final diagnosis. Group I comprised right congenital diaphragmatic hernia (RCDH) (n = 18), Group II comprised RCDH with sac (n = 6), the babies with diagnosis of right diaphragmatic eventration were included in Group III (n = 7), whereas babies with other right-sided diaphragmatic hernia defects diagnosis were included in Group IV (n = 2).Conclusion:Right-sided congenital diaphragmatic defects, though rare, do carry excellent survival if referred early and managed in a tertiary care neonatal and paediatric centre as that of left diaphragmatic defects.

Inter- and Intra-rater Reliability of A Grading System for Congenital Diaphragmatic Hernia Defect Size

BackgroundThe Congenital Diaphragmatic Hernia Study Group (CDHSG) registry is a multi-institutional tool to track outcomes of patients with CDH. The CDHSG asks surgeons to categorize diaphragmatic defect sizes as type A-D based on published guidelines. The reported size of the defect has been correlated with patient outcomes, but the reliability of this system has never been studied. Our goal was to evaluate the inter- and intra-rater reliability of the CDHSG grading system. Materials and methodsForty-six operative notes from CDH patients that underwent surgical repair at a single institution were collected and cropped to include only the information necessary to grade the hernia defect based on the CDHSG guidelines. The defects were graded by nine pediatric surgeons on two separate occasions (18 wk apart). Inter-rater reliability was calculated using a Cohen's kappa (κ). Intra-rater reliability was calculated using an intraclass correlation coefficient. ResultsInter-rater reliability was minimal to weak (κ round1 = 0.395, κ round2 = 0.424). Agreement ranged from 19.57% (κ = −0.0745) to 82.61% (κ = 0.7543). Inter-rater agreement was similar despite operative findings and outcomes: survival yes/no (κ = 0.3690, κ = 0.3518), need for ECMO yes/no (κ = 0.3323, κ = 0.3362), patch repair yes/no (κ = 0.2050, κ = 0.1916), and liver up/down (κ = 0.2941, κ = 0.4404).Intra-rater reliability was good to excellent (intraclass correlation coefficient = 0.88, 95% CI [0.83-0.92]). Agreement with oneself ranged from 71.74% to 93.48%. ConclusionsThe demonstrated weak inter-rater reliability of the current CDHSG grading system shows the need for improvement in how the grading system is applied by surgeons when reporting CDH defect size.

Surgical perspectives regarding application of biomaterials for the management of large congenital diaphragmatic hernia defects.

This review focuses on the surgical viewpoints on patch repairs in neonates with large congenital diaphragmatic hernia defects. The main focus is on the various biomaterials that have been employed to date with regard to their source of origins, degradation properties as well as tissue integration characteristics. Further focus is on the present knowledge on patch integration when biomaterials are placed in the diaphragmatic defect. The review will also look at the present evidence on the biomechanical characteristics of the most commonly used biomaterials and compares these materials to diaphragmatic tissue to offer more insight on the present practice of patch repairs in large defects. Since tissue engineering and regenerative medicine has offered another dimension to diaphragmatic replacement, a detailed overview of this technology will be undertaken with regard to cell sourcing, scaffolds, in vitro versus in vivo implants as well as quality of tissue produced, to explore the limitations and the feasibility facing the scientific community in its clinical implementation of skeletal muscle-engineered tissue beyond laboratory research for diaphragmatic replacement.

Engineering and repair of diaphragm using biosheet (a collagenous connective tissue membrane) in rabbits

BackgroundProsthetic patches can be used to repair large congenital diaphragmatic hernia defects but may be associated with infection, recurrence, and thoracic deformity. Biosheets (collagenous connective tissue membranes) have been used in regenerative medicine. We evaluated the efficacy of Biosheets in a rabbit model. MethodsBiosheets were prepared by embedding silicone plates in dorsal subcutaneous pouches of rabbits for 4weeks. In group 1 (n=11), Gore-Tex® sheets (1.8×1.8cm) were implanted into a diaphragmatic defect. In group 2 (n=11), Seamdura®, a bioabsorbable artificial dural substitute, was implanted in the same manner. In group 3 (n=14), biosheets were autologously transplanted into the diaphragmatic defects. All rabbits were euthanized 3months after transplantation to evaluate their graft status. ResultsHerniation of liver was observed in 5 rabbits (45%) in group 1, 8 (73%) in group 2, and 3 (21%) in group 3. A significant difference was noted between groups 2 and 3 (P=0.017). Biosheets had equivalent burst strength and modulus of elasticity as native diaphragm. Muscular tissue regeneration in transplanted biosheets in group 3 was confirmed histologically. ConclusionBiosheets may be applied to diaphragmatic repair and replacement of diaphragmatic muscular tissue. Level of evidenceLevel III.

Balloon removal after fetoscopic endoluminal tracheal occlusion for congenital diaphragmatic hernia

Isolated congenital diaphragmatic hernia defect allows viscera to herniate into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. Antenatal measurement of lung size and liver herniation can predict survival after birth. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion under local anesthesia. This in utero treatment requires a second intervention to reestablish the airway, either before birth or at delivery. To describe our experience with in utero endotracheal balloon removal. This is a retrospective analysis of prospectively collected data on consecutive patients with congenital diaphragmatic hernia treated in utero by fetal endoscopic tracheal occlusion from 3 centers. Maternal and pregnancy-associated variables were retrieved. Balloon removal attempts were categorized as elective or emergency and by technique (in utero: ultrasound-guided puncture; fetoscopy; ex utero: on placental circulation or postnatal tracheoscopy). We performed 351 balloon insertions during a 144-month period. In 9 cases removal was attempted outside fetal endoscopic tracheal occlusion centers, 3 of which were deemed impossible and led to neonatal death. We attempted 302 in-house balloon removals in 292 fetuses (217 elective [71.8%], 85 emergency [28.2%]) at 33.4 ± 0.1 weeks (range: 28.9-37.1), with a mean interval to delivery of 16.6 ± 0.8 days (0-85). Primary attempt was by fetoscopy in 196 (67.1%), by ultrasound-guided puncture in 62 (21.2%), by tracheoscopy on placental circulation in 30 (10.3%), and postnatal tracheoscopy in 4 cases (1.4%); a second attempt was required in 10 (3.4%) cases. Each center had different preferences for primary technique selection. In elective removals, we found no differences in the interval to delivery between fetoscopic and ultrasound-guided puncture removals. Difficulties during fetoscopic removal led to the development of a stylet to puncture the balloon, leading to shorter operating time and easier reestablishment of airways. In these fetal treatment centers, the balloon could always be removed successfully. In 90% this was in utero, with the use of fetoscopy preferred over ultrasound-guided puncture. Ex utero removal was a fall-back procedure. In utero removal does not seem to precipitate immediate membrane rupture, labor, or delivery, although the design of the study did not allow for a formal conclusion. For fetoscopic removals, the introduction of a stylet facilitated retrieval. Successful removal may rely on a permanently prepared team with expertise in all possible techniques.

Omentopexy for patch repair of diaphragmatic defect

There are many techniques in the reconstructive of congenital diaphragmatic hernia defect. In this study, we present our results from a prospective, randomised trial of using the omentum (omentopexy) for repair of large diaphragmatic defects. Twenty white, male, New Zealand rabbits were used to compare incidence and severity of adhesion bands formation in abdominal cavity with/without of omentopexy after repair of diaphragm defect with the non-absorbable patch (Dacron). They were divided in to two groups, GI (10 animals with omentopexy and repair) and GII (10 animals with repair, without omentopexy). On the 60 th day, animals were re-operated. In each case, adhesion band formation and its severity were recorded. The difference between the incidence of adhesion band formation among the two group was statistically significant (P = 0.019).The majority of rabbits in GII (60%) had substantial adhesion bands (Grade >2 or severe score), whereas, in GI, none of rabbits had substantial adhesion bands (P = 0.019). Our study showed that the use of omentopexy as a cover in repair of diaphragmatic defect is versatile technique with a good success for decreasing of adhesion band formations at short-term follow-up.

Split abdominal wall muscle flap repair vs patch repair of large congenital diaphragmatic hernias

Purpose Large congenital diaphragmatic hernias are commonly repaired with a prosthetic patch. We hypothesized that a split abdominal wall muscle flap would reduce the risk of recurrence. Methods A retrospective review of neonates with congenital diaphragmatic hernia in whom primary repair was not possible was performed. Kaplan-Meier analyses and Cox proportional hazards modeling were performed. Results Of 153 patients, 46 could not have repair with primary closure of the diaphragm. Thirty-three survived to discharge and were subjected to analysis for recurrence. Ten underwent repair with a patch, whereas 23 had a muscle flap (internal oblique and transversalis) patch. The groups were similar with regard to demographics, need for extracorporeal membrane oxygenation, repair on extracorporeal membrane oxygenation, and size of the defect. Fifty percent of patch repairs recurred with a median time of 0.5 years. Only one (4.3%) of the patients who had muscle flap patch developed a recurrence. This was significant on Kaplan-Meier analysis ( P = .0009) and had a hazard ratio of 14.3 on Cox regression ( P = .018). Median follow-up exceeded 4 years. No children required surgery for an abdominal wall hernia. Conclusions The split abdominal wall muscle flap allows for closure of large congenital diaphragmatic hernia defects with autologous tissue. This approach is associated with significantly fewer recurrences than patch repairs.

Incarcerated diaphragmatic hernia and cardiac tamponade

To the Editor, We present an unusual cause of tamponade-like presentation in a patient undergoing anesthesia. We briefly discuss the related pathophysiology and the need for vigilance in maintaining a broad differential diagnosis for critical events occurring in the operating room (OR). The patient gave written consent for publication of this report. A 76-yr-old male presented to hospital with sudden acute onset of abdominal pain and nausea. He was hemodynamically stable in the emergency department where blood tests revealed an elevated lactate level (3.4 mmoL L). Computed tomography of the patient’s abdomen showed a left diaphragmatic hernia defect and small bowel herniation. He was treated with antibiotics and fluid resuscitation by the surgical team while a plan for surgery was being formulated with the concern for potential bowel ischemia. The patient’s condition acutely deteriorated on the surgical floor. He developed increasing oxygen requirements and became hypotensive. Repeat investigations showed a serum lactate of 10.5 mmoL L with a blood pH of 7.19. The patient was transferred to the OR for emergency exploratory laparotomy and possible left thoracotomy for reduction of a suspected incarcerated paraesophageal hernia with bowel ischemia. On initial examination outside the OR, the patient was in obvious respiratory distress on 15 L oxygen with a nonrebreathing mask, and there were visible signs of air hunger with oxygen saturations in the 80’s. He was immediately transferred into the OR, and aggressive fluid resuscitation was initiated while preparing to secure the patient’s airway emergently. Rapid sequence induction was performed with propofol 30 mg iv, succinylcholine 120 mg iv, and tracheal intubation. The patient remained hypotensive with a systolic blood pressure of approximately 80 mmHg and a heart rate of 120 beats min despite fluid resuscitation. The initial central venous pressure (CVP) was 20 mmHg, and the peak airway pressures reached 40 cm H2O. An epinephrine infusion was initiated at a rate of 0.1 lg kg min. As surgery progressed and proceeded from a laparotomy to a thoracotomy, there was an audible decompression of the herniated bowel from the chest with an immediate resolution of the high airway pressures, tachycardia, and elevated CVP. The patient’s blood pressure and heart rate normalized, his urine output improved, and he was able to be weaned from the epinephrine infusion. The patient tolerated the remainder of the procedure well, and he was transferred to the intensive care unit. Subsequent review of his immediate preoperative chest x-ray showed left chest opacification and bowel herniation with right mediastinal shift (Fig. 1). The pathophysiology of this case can best be described as the patient having an incarcerated ischemic bowel in the chest producing cardiac compression and tamponade-like physiology. Reduction of the herniated bowel resulted in the immediate resolution of the patient’s hemodynamic instability. The patient’s postoperative chest x-ray showed resolution of the mediastinal shift (Fig. 2). Cardiac tamponade is a life-threatening slow or rapid compression of the heart due to the pericardial accumulation of fluid, pus, blood, clots, or gas resulting from effusion, trauma, or rupture of the heart. In this case, we believe that the incarcerated bowel became ischemic and edematous, causing extrinsic compression and displacement of the heart and resulting in cardiogenic shock. The x-ray of the patient at original presentation to the hospital K. J. McKeown, MD (&) W. Sischek, MD University of Western Ontario, London, ON, Canada e-mail: kevin.mckeown@utoronto.ca